Medical Claims Review: Reviewing medical claims related to cardiac catheterization procedures, including diagnostic tests, interventional procedures, and implantable device placements. Ensuring that claims are accurate, medically necessary, and compliant with policy terms and guidelines. Utilization Management: Assessing the appropriateness and efficiency of cardiac catheterization procedures performed in the cath lab. Utilizing clinical guidelines and evidence-based practices to evaluate treatment plans and ensure optimal utilization of healthcare resources. Pre-authorization: Reviewing requests for pre-authorization of cardiac catheterization procedures, such as angiograms, angioplasties, and stent placements. Determining medical necessity and approving coverage before services are rendered. Clinical Consultation: Providing medical expertise and guidance to claims adjusters, underwriters, and other insurance professionals on cardiac catheterization-related medical issues, procedural techniques, and treatment options. Health Education: Developing and delivering health education materials and programs to policyholders on cardiovascular health topics, including risk factors, prevention strategies, and treatment options for heart conditions. Clinical Review: Conducting clinical reviews of policyholders' medical records, imaging studies, and procedural reports for cardiac catheterization procedures. Assessing the appropriateness of interventions, adherence to clinical guidelines, and patient outcomes. Case Management: Providing support and coordination for patients undergoing cardiac catheterization procedures. Collaborating with healthcare providers to develop and implement care plans, monitor patient progress, and facilitate access to necessary cardiac services and resources. Medical Policy Development: Participating in the development and revision of medical policies, coverage guidelines, and reimbursement criteria for cardiac catheterization services. Ensuring that policies are based on clinical evidence, regulatory requirements, and industry standards. Quality Improvement: Participating in quality improvement initiatives aimed at enhancing the quality, safety, and effectiveness of cardiac catheterization procedures. Identifying opportunities for process improvements and implementing strategies to optimize patient outcomes. Compliance and Regulatory Affairs: Ensuring compliance with healthcare regulations, accreditation standards, and insurance industry guidelines related to cardiac catheterization services. Staying informed about changes in healthcare laws and policies that may impact insurance coverage and reimbursement practices.